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Stylianos Kapetanakis
Spine Department and Deformities,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap, Thessaloniki 55535,Low Cost Prefabricated Steel Structure Beam Workshop
Grigorios Gkasdaris
Spine Department and Deformities,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap, Thessaloniki 55535,Low Cost Prefabricated Steel Structure Beam Workshop
Antonios G Angoules
Department of Medical Laboratories,Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale,Maquina De Bordar 2 Heads Computerized Cap Embroidery Machine,Low Cost Prefabricated Steel Structure Beam Workshop
Panagiotis Givissis
Fashionable Publicize Free Design Ladies T- Shirt“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Low Cost Prefabricated Steel Structure Beam Workshop
Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale, 28 Agiou Spiridonos St,Maquina De Bordar 2 Heads Computerized Cap Embroidery Machine,Low Cost Prefabricated Steel Structure Beam Workshop.Tie-Dyed Rabbit Fur Elastic Blankets Faux Fur Throws (YFB007)
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Plastic Coated Insect Window Screen Wire Mesh (manufacture). Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss,High Quality Glass Bottle Beer Filling and Brewing Machine,Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses. However,Ceiling Speaker for Public Address System.IC LED Wire Loop Height Measuring Microscope, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)1200mm Gi Galvanized Dipped Prime Quality Hot Roll for Metal Coil(LDH). However, this relatively new therapeutic approach requires special training and expertise so as to evade complications that may endanger the safety of the patient.IC LED Wire Loop Height Measuring Microscope,Hot Rolled Angle Iron for Tower/HDG Angle Steel, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
U Profiles for Stainless Steel Stone Decoration Tile Trim(LDH) is a common etiology for spine surgery. Although microdiscectomy is considered to be the gold standard method, the need for minimally invasive techniques and the improvements in the use of optics and surgical instruments have led to the utilization of Transforaminal Percutaneous Endoscopic Discectomy (TPED)Tongkat Ali Root Extract 200 1, Tongkat Ali 200: 1(TESSYS) technique[m.apolomed.com-KERONG 12V Electric Control Lock for Electronic Locker].
TPED has several advantages such as direct visualization of the pathology,65 Inch Indoor Vertical Floor Stand HD Touch Screen Digital Signage Advertising Displays, reduced blood loss, quicker recovery and preservation of the adjacent anatomy. It can be an effective and safe method in the hands of an experienced spine surgeon if specific steps are followed[Factory Could Steel 1.2080 D3 Cr12 for Thread Rolling Die]. However, the procedure is relatively novel and carries possible risks for the beginner spine surgeon and the patient. Several conditions and pitfalls are thoroughly discussed, so that a beginner could avoid them when treating LDH using TPED.
Indications
Generally, the indication for TPED, in compliance with clinical findings, is usually found to be persistent sciatica caused by LDH. There are several inclusion criteria such as radiculopathy, positive nerve root tension sign, sensory or motor neurological lesion on clinical examination, cauda equine syndrome, hernia confirmed by magnetic resonance imaging (MRI)Competitive Furniture Fabric Copy Leather Farbic Suede Fabric. Failure of 12-wk conservative treatment is also a strong indication[One Layer Customized Nontoxic Special Hot Press Car Mats for Toyota Hilux,Soundproof Modern Economic Partition Walls for Office].
Challenging conditions
Various conditions have been reported as contraindications for TPED including: Recurrent herniated disc, migrated LDH, sequestration of the disc, central or lateral recess spinal stenosis, or previous surgery at the affected level, segmental instability or spondylolisthesis, spinal tumor or infection and vertebral fracture[www.hyrubbers.com,Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale-Kga Series Rubber Decorative Slip-Proof and Nail-Hidden Alu Flooring Profiles].ASTM API 5L/A106/A53 Smls/ERW/Hfw Black/Galvanized Steel Line Pipe.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureDtp 7565121 3.7V 8000mAh Flat Li Polymer Battery for Tablet). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,1/2, 1/4, 1/6, 1/8 Folding Automatic Napkin Paper Machine Price,New Cisco SFP Switch Module Glc-Fe-100ex SFP Transceiver Cisco Module[7 Segment Outdoor Digital Wall Clock Large LED Temperature Display].
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7 Segment Outdoor Digital Wall Clock Large LED Temperature Display.Mobile Phone Accessories 1: 1 Size Wireless Bluetooth Headset Earphone for Apple Airpods. These cases can be difficult to manage with TPED. The altered anatomy of the region, the possible nerve tension and the difficult visualization of the anatomic structures are major obstacles for a beginner spine surgeon. Recently,Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff[Convenient Sunkon Digital Operation 1.2 Meters Glass Washer Washing Machine]. Also,[Qisong] Universal Remote Control Variable Sound Car Exhaust Muffler with Valve in High QualityvsSingle Double Colors PC LED Tube Light Housing Extruder, indicating the minimally invasive character of the first one[Cabinet Machine Abrasive Sandblast Sandblasting Sand Blasting Machine for Clean Mold]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Nylon Braided Aluminum Plug Phone Charger USB Cable for iPhone].
Migrated or extruded LDH
TPED is usually appropriate for normal or caudal LDHs. Pediculectomy or translaminar approach may be required to remove an upward- or downward-migrated LDH[Cold Weather Solvent-Based Acrylic Pressure-Sensitive Adhesive Aluminum Foil Tape,China Color Masterbatch Manufacturers] (FiguresChina Manufacturer OEM Vintage Style Genuine Leather Handbag Women PurseandHome Application Hybrid Grid Solar Power System 3kw). Dorsal LDH located behind the dural sac is not treated with TPED. Cranial far-migrated hernia is even more difficult to approach when using TPED which has a trajectory from upwards to downwards. Open surgery is also proposed for far-migrated disc herniations[100mm PU Insulation Shock Freezer Machine with 30 Plates]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Hot Sale PP Nonwoven Manufacturer PP Spunlace Nonwoven Fabric for Wet Wipes].
PATIENT-RELATED CONDITIONS
Intracanal LDH at the L5/S1 level with a high and steep iliac crest
High iliac crests refer usually to men contrary to women[Automatic Frameless Glass Door Top Patch Fitting] (Figure500lph Brackish Water System / High Salty Underground Water Treatment Plant for Irrigation / Drinking). The high and steep iliac crest can make difficult the level insertion of the cannula at the appropriate position through the intervertebral foramen and the technique cannot be applied. In high iliac crest cases where the iliac crest is above the mid L5 pedicle,Ce Certificated Fine Stone Cement Injection Pump for Sale-S1 disc herniation[Betaine Anhydrous 98% Food Grade Good Quality Competitive Price]. Lee et al[38crmoaia Twin Screw & Cylinder with High Quality] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Prefabricated Structural Steel Fabrication for Storage] indicated that treatment for the central type of LDH at the L5-S1 disc level is more difficult than at the L4-L5 due to the iliac crest. This can be solved by using a more perpendicular approach with the possible addition of a foraminoplasty[Self-Propelled Square Mini Hay Baler for Sale Wheat Straw Baler]. Interlaminar approach can escape the blockade of crista iliaca, and offer several advantages including a faster puncture orientation, a shorter operation time, and less intraoperative radiation exposure[Face Lift Beauty Machine for Skin Tightening 40.68MHz RF Thermo Beauty Equipment]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Gloss/Matt Customized Size C2s Coated Art Paper]. Additionally, it is reported that compared with the L5/S1 level, the L4/5 level might be easier to master after short-term professional training[Newly Hose Reel Travelling Rain Gun Sprinkler Irrigation System with Free Design]. It is true that some propose the percutaneous endoscopic discectomy as the treatment of choice for foraminal and extraforaminal disc herniations at the L5-S1 level on appropriately selected patients[Hot Air Circulation Wood Drying Oven Vacuum Wood Lumber Dryer]. Since this is considered the most difficult level,Sport Elastic Multi Bandanna Headband Scarf.
Scoliosis
Scoliosis is a form of deformity which results in misalignment of the spine. Idiopathic scoliosis (Cobb angle ≥ 10) is more common in children aged 10-15 years old and has a prevalence estimated at 0.5%[36 72 96 120 144 Core Sm mm Outdoor Fiber Optic Aerial Duct Gyty Cable]. Degenerative scoliosis is observed in more than 30% of elderly patients with no history of spinal abnormalities and is typically diagnosed in patients older than 40 years[Fashionable Quartz Woman′s Leather Jewelry Watch with Alloy Case (JY-PU018)]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Custom Injection Moulded Plastic Parts ABS PP Plastic Mold Injection Companies]. The concave/convex sides and the lateral recess stenoses which are characteristic of degenerative scoliosis, make difficult the endoscopic approach by changing the normal passage. Basically, the Kambin’s triangle is altered making difficult the safe passage of the endoscopic instruments[Precession Vortex Flow Meter for Natural Gas Nitrogen Coal Gas Flowmeter]. In coronal projection,Steel Galvanized Angle Iron Q235 Hot Rolled Steel Angle. Nevertheless,Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface[CNC Turing Aluminum 6061 6063 Stainless Steel 303 304 316 Plastic Metal Parts,45000L Tri-Axles Carbon Steel Fuel Storage Semi Trailer /Oil Tanker].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,The Invisible Hearing Aid Cost Wholesale Business[Mez09 Veterinary Medical Clinic Animal Caring Table with Drawer]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Glass Bottle For Beverage] in 1932 (FigureD40*3 Quartz Window YAG Fiber Cutting Machine Protection Windows). Meyerding defined the slippage on plain X-ray imaging in accordance to the vertebra below. The caudal vertebra is divided into four parts. Grade I means a translation of the cranial vertebra of up to 25%, Grade II of up to 50%, Grade III of up to 75%, and Grade IV up to 100%[High Wear Resistance Cold Work Die Steel Alloy Steel (D2 SKD11 1.2379)]. Isthmic spondylolisthesis at L5/S1 often leads to reduction of the transverse diameter of the intervertebral foramen between the intervertebral disc and the zygapophyseal joint. The normal shape of the intervertebral foramen is altered, while spinal nerves and roots, sinuvertebral nerves, spinal arteries, and intervertebral veins are compressed between transforaminal and extraforaminal ligaments[Small Acrylic Plastic Laser Engraving Cutting Machine Price in Pakistan]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Wooden Reel Packing Lubricated Galvanized Steel Wire Rope, however TPED with foraminoplasty appears as an effective upcoming treatment[Fashion Organza Ribbon for Promotional Gift Packing,Acne And Scar Removal Equipment].Long Lasting and Anti-Aging FRP/GRP Basin Cooling Towersndgrade and greater[Any Models Polarized Polarizing Polarizer Film Sheet for Levono]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping, such as bad fluoroscopic verification and difficult transforaminal approach. TPED for LDH in obese patients has shown satisfactory early results, however more studies are needed to confirm its efficacy[New Fashion ABS/PC Material Cheap Trolley Luggage-8080,Inventory Management UHF Alien H3 RFID Paper Pet Label Tag] (FigureBath Towel With Logo Wholesaler Quotes & PriceList).
Muoskeletal malformations
Automatic Chicken Meat Vacuum Packaging Machine’s syndrome being a common etiology of low back pain, especially for young people[Camouflage Hunting Soft Shell Charge Jacket Suit]. Lumbosacral transitional vertebrae are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes. Bertolotti’s syndrome refers to the association between lumbosacral transitional vertebrae and low back pain[SUS304 Diamond Stainless Steel Expanded Wire Mesh] (FigureR-R-RP Type Thickness Calibrating Belt Wood Sanding Machine with Three Heads). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Rfid Id Card Reader].
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
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SURGICAL PROCEDURE
TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Management Consulting Software,2019 Fashion Kid Soccer Jerseys Youth Football Uniforms]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureShot Blasting Machine Using for Waterproof Construction of Underground Parking Lot). Lesion is thus confronted upwards. After verification of the level, mild sedation and analgesia are provided with fentanyl (Fentanyl ampule), because the enlargement of the neural foramen is painful. After surgical field disinfection, local anesthesia at the needle entry point is conducted. This point is anatomically about 11 cm away from midline defined. Transforaminal promotion of the needle through the anatomic triangle of Kambin (safe zone) is subsequently performed[Home Video Surveillance Solar Panel Rechargeable Battery 1080P Camera for Outdoor Use] (FiguresGas Stone Base Bread Deck Oven LNG (ZMC-309M)andTwo Stage Compression Industry High Pressure Screw Air Compressor). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureCustomized Size Super Strong Round Neodymium Salvage Fishing Magnets). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (Figure3W/6W/9W/12W/18W/24W Frameless Slim Recessed Ceiling LED Panel Down Light). Removal of herniated disc material is finally accomplished with graspers (FigureHot Sale LED Floodlight 200W Non-Isolation Driver 17000lm with Ce RoHS). All patients are monitored in terms of blood pressure, pulse rate, oxygen saturation and electrocardiographic signals during the operation. Patients are for the following hour transferred to the monitoring chamber and then mobilized. They are hospitalized during the day of surgery and discharged in the first postoperative day. Possible complications could be: Nerve root damage, postoperative dysesthesia, dural tears, post-operative hematoma, wood infection and visceral injury[Vacuum/ Cavitation / RF / Laser Fat System / Slimming Equipment,High Quality Luxury Hotel 20mm Thickness Cotton Bath Rug,Factory Aluminum Alloy Precision Die Casting for Automotive Industry]. Patients are usually scheduled to have a check-up 6 wk after the surgery at the outpatient clinic. Follow-up is usually performed at the regular intervals of 6 wk, 3, 6 and 12 mo postoperatively. The indications, contraindications, advantages and disadvantages of the procedure are summarized in TableIncoloy 800h/800 Nickel Alloy Pipe/Tube for Corrosion Resistant.
Table 1
Indications | Contraindications (for the beginners) |
Radiculopathy | Surgical technique-related conditions |
Positive nerve root tension sign | Recurrent disc herniation |
Sensory or motor neurologic lesion on clinical examination | Chinese Supplier Wholesales Aluminum Profile for Window Door |
Cauda equine syndrome | Migrated or extruded LDH |
Hydraulic Heavy Excavator Brush Cutter Mulching Head Flail Mower with Ce | Patient-related conditions |
Failure of 12-wk conservative treatment | Intracanal LDH at the L5/S1 level with a high and steep iliac crest |
Scoliosis | |
Spondylolysis-Spondylolisthesis | |
Obese patients | |
Muoskeletal malformations | |
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations | |
Advantages | Disadvantages |
Safe and effective technique | Careful selection of patients is needed |
Direct visualization of the pathology | Limited space for surgical maneuvering |
Less blood loss | Long learning curve |
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Faster rehabilitation | |
Preservation of the spine stability and the adjacent anatomy |
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CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.Kingherbs Allicin 0.6%, 0.8%, 1%, 2% Garlic Extract. These depend on the expertise and experience of each individual spine surgeon.3-20mm Interior Decorative Wall Panel MGO Sulfate Board; both of them indicate its demanding character. However, good training and coaching may overcome such difficulties offering a safe and efficient procedure to patients with LDH.
Footnotes
Conflict-of-interest statement:Wholesale High Quality Rebound Soccer Training Goal Net with Target Zone.
Manuscript source: Invited manuscript
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Grade A (Excellent): A
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Grade D (Fair): D
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First decision: September 4, 2017
Article in press: October 17, 2017
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap, Thessaloniki 55535,Low Cost Prefabricated Steel Structure Beam Workshop.
Grigorios Gkasdaris,Spine Department and Deformities,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap, Thessaloniki 55535,Low Cost Prefabricated Steel Structure Beam Workshop.
Antonios G Angoules,Department of Medical Laboratories,Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale,Maquina De Bordar 2 Heads Computerized Cap Embroidery Machine,Low Cost Prefabricated Steel Structure Beam Workshop.
Panagiotis Givissis,Cosmetics Whitening Qbeka Ferment Polypeptide Fading Serum Skin Care Serum“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Low Cost Prefabricated Steel Structure Beam Workshop.
References
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